Describe at least six guidelines for documenting in the patient's chart.

What will be an ideal response?


Print or write clearly. Be sure that your writing is neat and legible. Use the required color of ink. Do not use the term "patient" in your charting. Always chart in sequence. Indicate the specific time that an event occurred or a procedure was performed. Do not leave blank lines. Never erase or obliterate an error. Draw a single line through an incorrect entry, write "error," and your initials. Each time you make an entry, sign your name and your title. Make entries brief, concise, and accurate.

Nursing

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Mr. S, a 92-year-old patient in a geriatric medicine unit, has become acutely confused. The development is of great concern to the care team since Mr. S has no history of cognitive deficits. What action should the nurse prioritize?

A) Contacting Mr. S's family B) Assessing Mr. S's vital signs and obtaining blood samples C) Moving Mr. S to a bed that is visible from the nursing station D) Supervising Mr. S during transfers

Nursing

The patient is due to begin treatment with demecarium (Humorsol). The patient asks the health care provider why that particular drug was chosen to treat her glaucoma

The most appropriate response of the health care provider is that the drug is indicated for the treatment of glaucoma in patients who have:

Nursing

The nurse manager is explaining evidence-based practice (EBP) to the staff during a weekly meeting. Which statement should the manager use when explaining this approach to care?

1. "EBP expedites the assessment phase of the nursing process." 2. "EBP is a problem-solving approach to clinical practice questions." 3. "EBP is quicker than using the nursing process when providing patient care." 4. "EBP demonstrates an interest in furthering the development of nursing science."

Nursing

The clinic nurse is assessing how the prenatal client is meeting developmental tasks using Rubin's tasks, including which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply

1. Ensuring safe passage through pregnancy, labor, and birth. 2. Turning in on oneself to focus on the child. 3. Seeking commitment and acceptance of self as mother to the infant. 4. Completing the tasks of nesting at the appropriate time. 5. Seeking acceptance of the child by others.

Nursing